Cardiac cath help

Alfaro33

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93458 by MD
93454 by coworker
I am unsure.


Indication:
1. Angina pectoris functional class 3-4
2. Baseline abnormal EKG suggestive of anterolateral wall ischemia
3. Elevated coronary artery calcium score
4. Hypercholesterolemia and hypertension
5. Dyspnea upon exertion
6. Angina pectoris functional class 4 during recovery time after Lexiscan nuclear test today at this institution, terminating the test to proceed with cardiac catheterization
7. I explained to the patient the procedure of cardiac catheterization with all the potential risks and complications, the patient comprehended the discussion and consented
to proceed, he received intravenous heparin 8000 units pre procedure soon after the termination of the nuclear stress test listed earlier


CATHETERIZATION TECHNIQUE: After the usual preparation and premedication, the patient was brought to the cardiac catheterization laboratory.
Under sterile conditions, the right groin was prepped and 2% Xylocaine was used to infiltrate the skin. The right femoral artery was easily cannulated
and a 6-French sheath was left in place. After this, using a type 4, 6-French right and left Judkins catheter on appropriate guidewire, the left ventricle,
the right and left coronary arteries were selectively entered and opacified in the various oblique
projections using hand injections of contrast agent, and then these catheters were removed leaving the right groin sheath in place.

The existing right groin sheath was removed and was replaced by a 6 French Angio-Seal closure device with excellent hemostasis accomplished at the
right femoral arterial puncture site.


The patient tolerated the entire procedure very well and had no complication during or after the procedure.

Findings:

1. Right coronary artery: Dominant vessel, totally occluded in its mid segment with thrombus and receiving collaterals from the left coronary system
2. Left main trunk: Distal 40% stenosis, divides into LAD and circumflex
3. Left anterior descending coronary artery: Areas of ectasia and mild coronary artery disease
4. Left circumflex coronary artery: Areas of ectasia and mild coronary artery disease
5. Left ventricle: Ejection fraction 50-55%, left ventricular hypertrophy, LVEDP of 22 mm of mercury
6. Collaterals: From left coronary artery 2 totally occluded RCA to the site of occlusion and thrombus noted in the RCA.

Diagnosis:


1. Right coronary artery: This vessel is dominant and proximally the vessel shows coronary ectasia and in its mid segment the vessel is totally occluded and thrombus is present and
subsequent to that the vessel shows bifurcation into posterior ventricular posterior descending branch which are collateralized from the left coronary system
2. Left coronary artery: The left main trunk in its distal 3rd shows nearly 40% stenosis and divides into the left anterior descending and the left circumflex coronary arteries
3. Left anterior descending coronary artery: Shows mild coronary ectasia and mild coronary artery disease.
4. Left circumflex coronary artery: Shows coronary ectasia proximally and mild coronary artery disease of no significance including the obtuse marginal branch.
5. Collaterals: Excellent collaterals from the left coronary artery reaches all the way to the totally occluded segment of the right coronary artery where the thrombus is located
6. Left ventricle: The end-diastolic and systolic volumes are almost within normal limits with an overall ejection fraction is been approximately 55% with left ventricle hypertrophy,
the LVEDP is measured at 22 mm of mercury, there is no evidence for any aortic valve disease mitral valve disease or left ventricular outflow tract obstruction noted on the present study.

Recommandations:
1. I reviewed the findings of cardiac catheterization with the patient, the medical team and the physicians
2. Care of the right groin has been explained to the patient who comprehended the discussion and has agreed to comply
3. Cardiovascular risk modification , dual anti-platelet therapy as listed including Brilinta, follow-up nuclear stress test to test for ischemia
4. Medical therapy and cardiovascular exercise , follow-up in our office within the next several weeks on present medical therapy including aspirin 81 mg p.o. daily,
Brilinta 90 mg p.o. b.i.d., metoprolol XL 50 mg p.o. daily, lisinopril 10 mg p.o. daily.
 
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